Exhibit_B_FMS_CDRLs_DIDs.pdf

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PREVIOUS EDITION MAY BE USED.

DD FORM 1423, FEB 2024

Page of

INSTRUCTIONS FOR COMPLETING DD FORM 1423

(See DoDM 5010.12 for detailed instructions.)

DD FORM 1423, FEB 2024

Page of

CONTRACT DATA REQUIREMENTS LIST

C. CATEGORY:

14. DISTRIBUTION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft

Final

Reg

Repro

16. REMARKS

14. DISTRIBUTION

15.TOTAL

Image of arrow pointing towards totals

FOR GOVERNMENT PERSONNEL

Item A. Self-explanatory.

Item B. Self-explanatory.

Item C. Mark (X) appropriate category: TDP - Technical Data Package; TM - Technical Manual; Other - other category of data, such as "Provisioning," "Configuration Management," etc.

Item D. Enter name of system/item being acquired that data will support (e.g., Mission Design Series (MDS) designator).

Item E. Self-explanatory (to be filled in after contract award).

Item F. Self-explanatory (to be filled in after contract award).

Item G. Name of preparer of CDRL.

Item H. Date CDRL was prepared and signature of preparer of CDRL.

Item I. Name of CDRL approval authority.

Item J. Date CDRL was approved and signature of CDRL approval authority.

Item 1. See DFARS Subpart 204.71 for proper numbering. To add or delete additional data items, point and click the plus or minus sign to the right of Block J.

Item 2. Enter title as it appears on data acquisition document cited in Item 4.

Item 3. Enter subtitle of data item for further definition of data item (optional entry).

Item 4. Identify only one Data Acquisition Document No. If a single work task generates more than one deliverable data product, prepare a separate data item for each deliverable data product.

Item 5. Enter reference to tasking in contract that generates requirement for the data item (e.g., Statement of Work/Performance Work Statement paragraph number).

Item 6. Enter technical office responsible for ensuring adequacy of the data item.

Item 7. Specify requirement for inspection/acceptance of the data item by the Government.

Item 8. Specify requirement for approval of a draft before preparation of the final data item.

Item 9. For technical data and computer software, specify the contractor's requirement to mark the appropriate distribution statement on the technical data or computer software (ref. DoDI 5230.24).

Item 10. Specify number of times data items are to be delivered.

Item 11. Specify as-of date of data item, when applicable.

Item 12. Specify when first submittal is required.

Item 13. Specify when subsequent submittals are required, when applicable.

Item 14. Enter addressees and number of draft/final copies to be delivered to each addressee. Explain reproducible copies in Item 16.

Item 15. Enter total number of draft/final copies to be delivered.

Item 16. Use for additional/clarifying information for Items 1 through 15. Examples are: Tailoring of documents cited in Item 4; Clarification of submittal dates in Items 12 and 13; Explanation of reproducible copies in Item 14; Desired medium for delivery of the data item.

Identify for which data item additional remarks are provided. When tailoring the Data Acquisition Document invoked in Item 4, identify which portions of that Document are being tailored.

Identify any referenced attachments to the form. Attachments can be added using the button at the bottom of page 1.

FOR THE CONTRACTOR

Item 17. Specify appropriate price group from one of the following groups of effort in developing estimated prices for each data item listed on the DD Form 1423.

a. Group I. Definition - Data which is not otherwise essential to the contractor's performance of the primary contracted effort (production, development, testing, and administration) but which is required by DD Form 1423.

Estimated Price - Costs to be included under Group I are those applicable to preparing and assembling the data item in conformance with Government requirements, and the administration and other expenses related to reproducing and delivering such data items to the Government.

b. Group II. Definition - Data which is essential to the performance of the primary contracted effort but the contractor is required to perform additional work to conform to Government requirements with regard to depth of content, format, frequency of submittal, preparation, control, or quality of the data item.

Estimated Price - Costs to be included under Group II are those incurred over and above the cost of the essential data item without conforming to Government requirements, and the administrative and other expenses related to reproducing and delivering such data item to the Government.

c. Group III. Definition - Data which the contractor must develop for his internal use in performance of the primary contracted effort and does not require any substantial change to conform to Government requirements with regard to depth of content, format, frequency of submittal, preparation, control, and quality of the data item.

Estimated Price - Costs to be included under Group III are the administrative and other expenses related to reproducing and delivering such data item to the Government.

d. Group IV. Definition - Data which is developed by the contractor as part of his normal operating procedures and his effort in supplying these data to the Government is minimal.

Estimated Price - Group IV items should normally be shown on the DD Form 1423 at no cost.

Item 18. For each data item, enter an amount equal to that portion of the total price which is estimated to be attributable to the production or development for the Government of that item of data.

These estimated data prices shall be developed only from those costs which will be incurred as a direct result of the requirement to supply the data, over and above those costs which would otherwise be incurred in performance of the contract if no data were required. The estimated data prices shall not include any amount for rights in data. The Government’s rights to use the data shall be governed by the pertinent provisions of the contract.

9.0.0.2.20120627.2.874785

DD Form 1423, "Contract Data Requirements List"

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CurrentPage:

PageCount:

Select Classification from drop-down list.: 1

DI:

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A. CONTRACT LINE ITEM NUMBER:

exhibit: A

C. CATEGORY: Select for "TDP.": 0

C. CATEGORY: Select for "TM.": 0

C. CATEGORY: Select for "OTHER.": 1

C. CATEGORY: Enter specification for "Other.":

System: F100-PW-229 Augmentor Fuel Control/Pump

ContractNum: FD2030-24-31636

Contractor:

1. DATA ITEM NUMBER:

titleDataItem: Production Report for contractor shipment of F100-PW-229 AFC/P subtitle: None

4. AUTHORITY (Data Acquisition Document Number): DI-MGMT-80368A contractRef:

reqOffice: AFLCMC/LPSID

7. DD 250 REQUIREMENT: N/A

8. APPROVAL CODE : N/A

9. DISTRIBUTION STATEMENT REQUIRED: N/A

freq: Monthly asOfDate: N/A dateFirstSub: See Block 16 dateSubseqSub: See Block 16

16. REMARKS: BLOCK 4: DID IS TAILORED AS FOLLOWS:

THE CONTRACTOR SHALL PREPARE AND FURNISH A MONTHLY CUMULATIVE STATUS REPORT FOR ALL ITEMS THAT HAVE BEEN PLACED ON CONTRACT. THE REPORT SHALL INCLUDE: SERIAL NUMBER, CONTRACT OR EXHIBIT LINE ITEM NUMBER, ASSET RECEIVED DATE, ASSET INDUCTION DATE, PART-NUMBER, NATIONAL STOCK NUMBER, NOMENCLATURE, QUANTITY PLACED ON ORDER, QUANTITY SHIPPED, QUANTITY REMAINING TO BE SHIPPED, DATE OF SHIPMENT, FORECAST COMPLETION DATE, DOCUMENT CONTROL NUMBER, DELIVERY ORDER NUMBER AND SHIPMENT TRACKING NUMBER. REPORT SHALL BE FURNISHED IN DELIVERY ORDER SEQUENCE. THE REPORT SHALL BE PREPARED AS OF THE LAST WORKING DAY OF EACH MONTH AND FORWARDED BY E-MAIL NO LATER THAN THE 5TH WORKING DAY OF THE FOLLOWING MONTH. THE INITIAL REPORT WILL BE PREPARED FOR THE MONTH DURING WHICH THE CONTRACT PURCHASE REQUEST IS RECEIVED. REPORTS WILL CONTINUE TO BE FORWARDED UNTIL ALL OPEN DELIVERY ORDERS ARE SHIPPED COMPLETE. THE LAST REPORT WILL BE ANNOTATED “FINAL REPORT”. CONTRACTOR FORMAT IS ACCEPTABLE. REPORTS ARE TO BE LABELED CUI.

ANY DELAYS OR SLIPPAGE TO FORECAST COMPLETION DATE AND/OR ASSET DELIVERY SHALL BE COMMUNICATED TO LPSIB VIA DETAILED E-MAIL OR PHONE CONVERSATION. DETAILED INFORMATION SHALL INCLUDE, BUT NOT BE LIMITED TO, CAUSE FOR DELAY/SLIPPAGE (I.E., PARTS CONSTRAINTS, TEST-STAND ISSUES, PERSONNEL SHORTAGE, ETC.,).

FOR E-MAIL ADDRESS & ADDITIONAL PHONE NUMBERS CALL JAMES DEVANEY

AT 405-734-6717 OR E-MAIL james.devaney.2@us.af.mil

AFLCMC/LPSID POCs RECEIVING PRODUCTION REPORT:

AFLCMC.LPSIRep-Ret.Workflow@us.af.mil james.devaney.2@us.af.miil guy.bierwirth@us.af.mil

Click to add continuation field for Remarks:

14. DISTRIBUTION - a. ADDRESSEE, new line: AFLCMC/LPSID

14. DISTRIBUTION - a. ADDRESSEE, new line: DCMA/ACO

14. DISTRIBUTION - a. ADDRESSEE, new line: AFSC/PCO

15.TOTAL - Total draft copies is automatically calculated.:

15.TOTAL - Total final regular copies is automatically calculated.: 1

15.TOTAL - Total final regular copies is automatically calculated.: 1

15.TOTAL - Total final regular copies is automatically calculated.: 1

15.TOTAL - Total final reproducible copies is automatically calculated.:

priceGrp:

estTotalPrice:

remarks:

preparedBy: James E. DeVaney, Jr.

J. SIGNATURE: H. SIGNED ON 20260203

J. SIGNATURE: J. SIGNATURE

J. SIGNATURE:

approvedBy: Marcus Balano

Click to add additional data items.:

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Windows is either a registered trademark or a trademark of Microsoft Corporation in the United States and/or other countries. Mac is a trademark of Apple Inc., registered in the United States and other countries. Linux is the registered trademark of Linus Torvalds in the U.S. and other countries.

PREVIOUS EDITION MAY BE USED.

DD FORM 1423, FEB 2024

Page of

INSTRUCTIONS FOR COMPLETING DD FORM 1423

(See DoDM 5010.12 for detailed instructions.)

DD FORM 1423, FEB 2024

Page of

CONTRACT DATA REQUIREMENTS LIST

C. CATEGORY:

14. DISTRIBUTION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft

Final

Reg

Repro

16. REMARKS

14. DISTRIBUTION

15.TOTAL

Image of arrow pointing towards totals

FOR GOVERNMENT PERSONNEL

Item A. Self-explanatory.

Item B. Self-explanatory.

Item C. Mark (X) appropriate category: TDP - Technical Data Package; TM - Technical Manual; Other - other category of data, such as "Provisioning," "Configuration Management," etc.

Item D. Enter name of system/item being acquired that data will support (e.g., Mission Design Series (MDS) designator).

Item E. Self-explanatory (to be filled in after contract award).

Item F. Self-explanatory (to be filled in after contract award).

Item G. Name of preparer of CDRL.

Item H. Date CDRL was prepared and signature of preparer of CDRL.

Item I. Name of CDRL approval authority.

Item J. Date CDRL was approved and signature of CDRL approval authority.

Item 1. See DFARS Subpart 204.71 for proper numbering. To add or delete additional data items, point and click the plus or minus sign to the right of Block J.

Item 2. Enter title as it appears on data acquisition document cited in Item 4.

Item 3. Enter subtitle of data item for further definition of data item (optional entry).

Item 4. Identify only one Data Acquisition Document No. If a single work task generates more than one deliverable data product, prepare a separate data item for each deliverable data product.

Item 5. Enter reference to tasking in contract that generates requirement for the data item (e.g., Statement of Work/Performance Work Statement paragraph number).

Item 6. Enter technical office responsible for ensuring adequacy of the data item.

Item 7. Specify requirement for inspection/acceptance of the data item by the Government.

Item 8. Specify requirement for approval of a draft before preparation of the final data item.

Item 9. For technical data and computer software, specify the contractor's requirement to mark the appropriate distribution statement on the technical data or computer software (ref. DoDI 5230.24).

Item 10. Specify number of times data items are to be delivered.

Item 11. Specify as-of date of data item, when applicable.

Item 12. Specify when first submittal is required.

Item 13. Specify when subsequent submittals are required, when applicable.

Item 14. Enter addressees and number of draft/final copies to be delivered to each addressee. Explain reproducible copies in Item 16.

Item 15. Enter total number of draft/final copies to be delivered.

Item 16. Use for additional/clarifying information for Items 1 through 15. Examples are: Tailoring of documents cited in Item 4; Clarification of submittal dates in Items 12 and 13; Explanation of reproducible copies in Item 14; Desired medium for delivery of the data item.

Identify for which data item additional remarks are provided. When tailoring the Data Acquisition Document invoked in Item 4, identify which portions of that Document are being tailored.

Identify any referenced attachments to the form. Attachments can be added using the button at the bottom of page 1.

FOR THE CONTRACTOR

Item 17. Specify appropriate price group from one of the following groups of effort in developing estimated prices for each data item listed on the DD Form 1423.

a. Group I. Definition - Data which is not otherwise essential to the contractor's performance of the primary contracted effort (production, development, testing, and administration) but which is required by DD Form 1423.

Estimated Price - Costs to be included under Group I are those applicable to preparing and assembling the data item in conformance with Government requirements, and the administration and other expenses related to reproducing and delivering such data items to the Government.

b. Group II. Definition - Data which is essential to the performance of the primary contracted effort but the contractor is required to perform additional work to conform to Government requirements with regard to depth of content, format, frequency of submittal, preparation, control, or quality of the data item.

Estimated Price - Costs to be included under Group II are those incurred over and above the cost of the essential data item without conforming to Government requirements, and the administrative and other expenses related to reproducing and delivering such data item to the Government.

c. Group III. Definition - Data which the contractor must develop for his internal use in performance of the primary contracted effort and does not require any substantial change to conform to Government requirements with regard to depth of content, format, frequency of submittal, preparation, control, and quality of the data item.

Estimated Price - Costs to be included under Group III are the administrative and other expenses related to reproducing and delivering such data item to the Government.

d. Group IV. Definition - Data which is developed by the contractor as part of his normal operating procedures and his effort in supplying these data to the Government is minimal.

Estimated Price - Group IV items should normally be shown on the DD Form 1423 at no cost.

Item 18. For each data item, enter an amount equal to that portion of the total price which is estimated to be attributable to the production or development for the Government of that item of data.

These estimated data prices shall be developed only from those costs which will be incurred as a direct result of the requirement to supply the data, over and above those costs which would otherwise be incurred in performance of the contract if no data were required. The estimated data prices shall not include any amount for rights in data. The Government’s rights to use the data shall be governed by the pertinent provisions of the contract.

9.0.0.2.20120627.2.874785

DD Form 1423, "Contract Data Requirements List"

Hide Attachment Bar

CurrentPage:

PageCount:

Select Classification from drop-down list.: 1

DI:

Click on this button to attach a file(s).:

A. CONTRACT LINE ITEM NUMBER:

exhibit: A

C. CATEGORY: Select for "TDP.": 0

C. CATEGORY: Select for "TM.": 0

C. CATEGORY: Select for "OTHER.": 1

C. CATEGORY: Enter specification for "Other.":

System: F100-PW-229 Augmentor Fuel Control/Pump

ContractNum: FD2030-24-31636

Contractor:

1. DATA ITEM NUMBER:

titleDataItem: DEFICIENCY REPORT (DR) subtitle: None

4. AUTHORITY (Data Acquisition Document Number): DI-PSSS-81535B contractRef:

reqOffice: AFLCMC/LPSID

7. DD 250 REQUIREMENT: N/A

8. APPROVAL CODE : N/A

9. DISTRIBUTION STATEMENT REQUIRED: N/A

freq: As Required asOfDate: N/A dateFirstSub: See Block 16 dateSubseqSub: See Block 16

16. REMARKS: As defined by T.O. 00-35D-54, submit a report whenever a material or a quality deficiency occurs utilizing SF Form 368.

THIS CDRL WILL SERVE BASIC YEAR AND ALL OPTION YEARS

Ref: Block 14a: Complete address for distribution:

AFLCMC/LPSID

3001 Staff Dr., Ste. 2AE1107B Tinker AFB, OK. 73145-3031 james.devaney.2@us.af.mil 405-734-6717

DCMA/ACO (See the face contract)

Click to add continuation field for Remarks:

14. DISTRIBUTION - a. ADDRESSEE, new line: AFLCMC/LPSID

14. DISTRIBUTION - a. ADDRESSEE, new line: DCMA/ACO

15.TOTAL - Total draft copies is automatically calculated.:

15.TOTAL - Total final regular copies is automatically calculated.: 1

15.TOTAL - Total final regular copies is automatically calculated.: 1

15.TOTAL - Total final reproducible copies is automatically calculated.:

priceGrp:

estTotalPrice:

remarks:

preparedBy: James E. DeVaney, Jr.

J. SIGNATURE: H. SIGNED ON 20260203

J. SIGNATURE: J. SIGNATURE

J. SIGNATURE:

approvedBy: Marcus Balano

Click to add additional data items.:

Click to delete additional data items.:

DATA ITEM DESCRIPTION

Title: Status Report

Number: DI-MGMT-80368A Approval Date: 30 OCT 2006 AMSC Number: 7619 Limitation: N/A DTIC Applicable: No GIDEP Applicable: No Office of Primary Responsibility: NS/DA02 Applicable Forms: N/A

Use/relationship:

The Status Report documents the status of contractor effort towards achieving contract objectives. It identifies accomplishments to date and difficulties encountered, and compare the status achieved to planned goals and the resources expended. It is used by the Government to monitor and evaluate contractor performance.

This Data Item Description (DID) contains format and content preparation instructions for the data product generated by the specific and discrete task requirement as delineated in the contract.

It is not intended that all requirements herein should be applied to every program.

Portions of the DID are subject to tailoring by deletion depending on the specific status reporting requirements of the project.

This DID is related to DI-FNCL-80331, Funds and Man-Hour Expenditure Report which can be used in conjunction with this report if paragraph 3.2.3 below is deleted.

This DID supersede DI-MGMT-80368.

Requirements:

1. Reference documents. None.

2. Format. The Status Report shall be in contractor format.

2.1 Identification. The data indicated below shall be contained on a title page or on the first page of the report.

a. Title/identification of the system/component/program/project.

Source: http://assist.dla.mil -- Downloaded: 2023-05-02T13:31Z Check the source to verify that this is the current version before use.

DI-MGMT-80368A

b. Type of report (e.g., monthly, interim, final).

c. Period covered by the report.

d. Contract number.

e. Preparing activity or contractor’s title.

f. Security classification, when required.

g. Distribution Statement.

2.2 Page size. The report shall be on 8 ½ by 11 inch (metric A4) paper.

3. Content. The report shall contain the following:

3.1 Summary. The summary shall include a brief statement of the overall project status , covering the accomplished technical activities and development, objectives of efforts, summary results of efforts, identification of major problems/deficiencies with impact, and recommended solutions.

3.2 Body of report. The Status Report shall contain the following items, where applicable:

3.2.1 Milestone/task status. The status of each milestone/task as defined by the statement of work or contract, as applicable:

a. A statement as to whether or not the program/project/task is on schedule; if not, the effort planned to meet the schedule shall be indicated. Include an overall status of each milestone, task, or unit of work. Include update schedule sheets, milestone charts, or task synopsis sheets identifying phase of task and percentage of completion of each task, technical instruction, or order.

b. A comparison of achieved end-product performance capabilities projected against contract baseline values, requirements, or allocations.

c. Effort expended on each task to date, and a brief description of technical developments and accomplishments.

d. Key dates in any testing program and description of tests performed and significant test results. If applicable, a description of the amount and type of down time on the equipment or system under test.

e. A list of all designs completed and a brief description of each item. For designs in process, provide estimated dates for design and drawing completion.

f. A narrative of outstanding problems existing as of the previous status report, and their resolution status. 2

DI-MGMT-80368A

g. New problem areas encountered or anticipated, their effect on the overall work effort/project and steps being taken to remedy problem situations.

h. Significant results of conferences, trips, or directives for the Contracting officer’s representatives.

i. Any other information which may cause significant changes in the program schedule.

3.2.2 Future plans. Summary of future plans, recommendations and proposals both for the next reporting period and for any long term plans.

3.2.3 Itemized man-hours and costs. Itemized man-hour and cost expenditure incurred for the reporting period by category and task, total contractual expenditures, and funds remaining as of the reporting date.

3.2.4 Contract deliveries status. The status of each deliverable end item, including data deliverables, as required by the contract. Provide item and contract identification, shipping/transmittal data, acceptance status, security classification, and schedule due date information.

3.2.5 Report preparer. Name of person(s) preparing report and telephone number(s).

3.3 Appendices. Appendices where applicable, for tables, references, charts, or other descriptive material. Each appendix shall be identified and referenced in the appropriate area of the report.

4. END OF DI-MGMT-80368A

DATA ITEM DESCRIPTION

Requirements:

DATA ITEM DESCRIPTION

Title: ACQUISITION AND SUSTAINMENT DATA PACKAGE (ASDP) DEFICIENCY REPORT

(DR)

Number: DI-PSSS-81535B Approved Date: 20220715 AMSC Number: F10333 Limitation: N/A DTIC Applicable: No GIDEP Applicable: No Preparing Activity: 11 (AFLCMC/EZSC) Project Number: PSSS-2022-005 Applicable Forms: N/A

Use/Relationship: The Acquisition and Sustainment Data Package (ASDP) Deficiency Report (DR) provides complete and accurate deficiency identification on government furnished material (GFM) in acquisition or repair contracts by contractors to the Government. This information is used by the Government to identify necessary corrective action in accordance with T.O. 00-35D-54, USAF Deficiency Reporting, Investigation, and Resolution (DRI&R).

(Copies of this document are available online at https://www.tinker.af.mil/Resources/Technical- Orders/.)

a. This Data Item Description (DID) contains the format, content, and intended use information for the data deliverable resulting from the work task described in the solicitation.

b. This DID is applicable when contractors are responsible for maintaining custodial records for government property being repaired.

c. This DID interrelates with DI-MGMT-80258, Acquisition and Sustainment Data Package (ASDP) Material Improvement Project (MIP) Report.

(Copies of this document are available online at https://quicksearch.dla.mil.)

d. This DID supersedes DI-PSSS-81535A.

Requirements:

1. Reference documents. The applicable issue of the documents cited herein, including their approval dates and dates of any applicable amendments, notices, and revisions, shall be as specified in the contract.

2. Format. The ASDP Deficiency Report shall be in a text searchable format. The Data Objects/Attributes and Associated Metadata (DOAM) listing shall be in Microsoft Excel spreadsheet format in accordance with the template provided in the DOAM Specification attached to the contract. All data shall be in the English language.

3. Content. The Deficiency Report content shall be as described in Table I.

3.1 DOAM. The completed Deficiency Report template, provided in the DOAM Specification attached to the contract, shall comply with the format requirements (see 2. above) so that it can be ingestible into a Product Lifecycle Management (PLM) solution to ensure proper tying, tracing, and linking to the lowest component of the end item to which the delivered Deficiency Report Information is applicable. Any field that is not applicable shall be marked “NA.”

Source: http://assist.dla.mil -- Downloaded: 2023-05-02T13:13Z https://www.tinker.af.mil/Resources/Technical-Orders/ https://www.tinker.af.mil/Resources/Technical-Orders/ https://quicksearch.dla.mil/

DI-PSSS-81535B

TABLE I. Deficiency Report Content.

1. From: Address of Originating Activity

2. To: Office of Primary Responsibility (OPR) for the equipment. Refer to T.O.

00-35D-54 for guidance on Screening Points.

Subject: First Part as applicable:

a. Category I Deficiency Report (CAT I DR)

b. Category II Deficiency Report (CAT II DR)

c. Report Control Number (RCN): An RCN consists of three parts. The first part will be the DoD Activity Address Code (DoDAAC).

The second part will be the last two digits of the calendar year.

The third part will be a 4-digit sequence number that is locally assigned.

3. Description of Deficiency:

Describe in detail what is wrong, the circumstances prior to the difficulty, probable cause, any action taken, and recommendations. Attach copy of supporting documents. Continue on separate sheet if necessary.

4. Date of Deficiency: Year, month, day deficiency was discovered.

5. National Stock

Number (NSN) NSN and applicable Material Management Aggregation Code (MMAC) of item (see D043 or D086).

6. Nomenclature Noun of item for which report is submitted. Software DRs shall provide nomenclature of programmable hardware.

7. Operating Time at Failure

Hours, cycles, days, miles rounds or others

8. Deficient Item Part Number

Complete Manufacturer part number. If Computer Identification Number (CPIN) is associated with a computer program it shall also be provided.

9a. Manufacturer’s CAGE Code

Unique code assigned to suppliers of government or defense agencies.

9b. Manufacturer/Shipper/ City/State

Complete address of manufacturer or shipper.

10. Quantity Number received, inspected, deficient, and in stock.

11. Serial, lot or batch number Complete item serial number.

12a. Item new, repaired or overhauled

Use one to identify item as appropriate.

12b. Date Manufacturer, Repaired or Overhauled

Year/Month/Day

DI-PSSS-81535B

12c. Last Repair Facility CAGE/DoDAAC/Address

13a. Contract Number Obtain contract number from records service tag, manufacturer/container label, etc. Contract number is critical to processing reports.

13b. Requisition/Document Number

Obtain from tags/labels on item packaging.

13c. Purchase Order Number.

The Purchase Order Number associated with the defective part. This can usually be found on the attached shipping document. This field can also be used to annotate the Delivery Order number (products/supplies) or Task Order number (tasks/services) if known or applicable.

14. Government Furnished Material (GFM)

Yes/No/Unknown

15a. Item Under Warranty Yes/No/Unknown 15b. Warranty Expiration

Date Provide if known.

16. End Item Enter the applicable Equipment Item Code (EIC), Work Unit Code (WUC), or Table of Authorized Material Control Number (TAMCN) for the deficient material.

17. Next Higher Assembly a. NSN – National Stock Number associated with the next higher assembly.

b. NOMENCLATURE – Item name of the next higher assembly.

c. PART NUMBER – Part number assigned to the next higher assembly.

d. SERIAL NUMBER – Serial number from the next higher assembly.

18. End Item a. NSN – National Stock Number associated with the end item.

b. NOMENCLATURE – Name of the end item.

c. TYPE/MODEL – Type or model assigned to the end item configuration.

d. SERIAL NUMBER – Serial number from the end item equipment or system.

19. Current Disposition of Deficient Item

Holding/Disposed or Destroyed/Repaired/Other

20. Location of Deficient Material

Enter the name and location or supply activity that is currently holding the exhibit/deficient material.

End of DI-PSSS-81535B.